Status of Public Health -- Bosnia and Herzegovina,
August-September 1993

Since 1991, civil strife in the former Yugoslav republics
(Figure_1) has resulted in more than 150,000 war-related
casualties
(1), approximately 3.5 million displaced persons (2), widespread
destruction of the health infrastructure, disruption of food
production and distribution, and other increased risks to public
health. The impact of the war has been especially severe in Bosnia
and Herzegovina (1991 population: 4.3 million) (1). To assist in
targeting humanitarian aid to the region, in August 1993, the U.S.
Agency for International Development's Office of Foreign Disaster
Assistance asked CDC to assess the public health status and needs
of Bosnia and Herzegovina. This report summarizes the results of
that assessment and focuses on three central Bosnian regions.

This assessment was based on interviews with local public
health officials and international humanitarian aid workers;
reviews of data collected by local public health institutions and
results of surveys conducted by United Nations (UN) agencies and
nongovernment organizations (NGOs); and observations in central
Bosnia (regions of Sarajevo, Zenica, and Tuzla) and Herzegovina.
Because of security and time constraints, primary data could not be
collected.

The principal public health impact of the war has been
injuries resulting from war-related trauma. In Sarajevo, the war
accounted for more than 6800 deaths from trauma (57% of all
reported mortality) and 16,000 wounded persons during April 1992-
March 1993 (3). In addition, the increase in the crude mortality
rate reported in Sarajevo (2.9 deaths per 1000 population in April
1993 compared with 0.8 per month in 1991) was attributed to these
casualties (3). In the Zenica Provincial Hospital, the proportion
of surgical cases associated with trauma increased from 22% in
April 1992 (the month the war began) to a peak of 78% in December
1992 and declined to 40% in August 1993. Overall, 60% of surgical
cases from July 1992 through August 1993 were war-related injuries.

Based on estimates of the Office of the United Nations High
Commissioner for Refugees (UNHCR), the number of persons displaced
from their homes in Bosnia and Herzegovina from January 1993
through August 1993 increased from 810,000 to approximately 2
million (2). In August 1993, approximately 90% of displaced persons
were living in private homes, and 10% were housed in collective
centers maintained by local and international humanitarian aid
agencies.

Although increased numbers of displaced persons and the
disruption of local agricultural production have intensified needs
for international food aid, military forces representing different
factions have intermittently blocked access by UN food convoys to
central Bosnia. In August 1993, UNHCR was able to transport only
57% of basic food requirements for beneficiaries in the Zenica
region and only 39% of requirements for the Tuzla region. Despite
these limited rations, nutrition surveys conducted by the World
Health Organization (WHO) in central Bosnia in July 1993 did not
detect an increased prevalence of protein-energy malnutrition --
even though the mean weight loss for adults in Sarajevo since April
1992 has been 10-12 kg per person (4,5).

The incidence of diagnosed cases of hepatitis A and other
enteric diseases has increased in all areas of central Bosnia since
the beginning of the war (Republic Institute for Public Health of
Bosnia and Herzegovina, unpublished data, 1993; 6) (Table_1).
The
increased occurrence of enteric diseases reflects deterioration in
the quantity and quality of water supplies that has resulted from
diverted water sources, cracked water pipes, lack of diesel to run
water pumps, and frequent losses of water pressure that, in turn,
permit cross-contamination by sewage. In August 1993, for example,
piped water supplies in Sarajevo were restricted to an average of
5 liters per person per day (WHO recommends daily provision of 20
liters per person to maintain health).

Although some elements of the public health system continue to
function, in most areas, routine prevention programs have been
curtailed. For example, in central Bosnia from June 1991 through
July 1993, 33% of children aged 13-25 months had been vaccinated
against measles compared with coverage rates of 90%-95% in 1990
(4). However, since April 1992, no outbreaks of measles had been
reported (6). In Sarajevo, during April 1992-July 1993, inadequate
prenatal-care services contributed to increases in spontaneous
abortions (64%) and perinatal mortality (70%) and a 19% decrease in
average birthweight (S. Simic, MD, Kosevo Hospital, Sarajevo,
personal communication, 1993).

These prevention and other primary-care programs have been
limited because of decreased access to the population, damaged
health-care facilities, and inadequate supplies and resources. An
especially critical supply hindered by the military blockade has
been diesel, which cost $36 U.S. per gallon on the illegal market
in Sarajevo in August 1993. Because of this fuel shortage, water
pumps cannot function, health-care workers cannot travel to rural
clinics, and some public health programs (e.g., garbage collection
and vaccination campaigns) have been curtailed.
Reported by: Republic Institute for Public Health of Bosnia and
Herzegovina, Sarajevo, Zenica, and Tuzla. Office of the World
Health Organization, Regional Office for Europe, Special
Representative of the Regional Director, Zagreb, Croatia. US Office
of Foreign Disaster Assistance, Washington, DC. Technical Support
Div, International Health Program Office, CDC.

Editorial Note

Editorial Note: During war-related emergencies in developing
countries, infectious diseases consistently have been reported as
the leading cause of morbidity and mortality in the affected
civilian populations (7). However, the proportion of deaths in the
civilian population attributed to war-related injuries in Bosnia is
among the highest documented in recent humanitarian emergencies
related to civil war (7). By comparison, population surveys in
central and southern Somalia determined that trauma deaths
accounted for 4%-11% of mortality during April 1992-January 1993
(CDC, unpublished data, 1993).

Although increases in enteric disease-related mortality have
not been reported, the fivefold to 16-fold increases in the
incidence rates of diarrheal disease and hepatitis A from 1990
through 1993 in three central Bosnian regions underscore the urgent
need for improvements in water and sanitation. Rates of infectious
diseases in Bosnia are lower than those reported in civil wars in
developing countries and may reflect at least five factors: 1)
disease reporting has been incomplete; 2) most displaced persons
are residing in private homes rather than in mass camps; 3)
elements of a previously well functioning local public health
system are still operating; 4) public health efforts of UN agencies
and NGOs have supplemented local programs; and 5) a well educated,
resourceful population has maintained relatively high standards of
personal hygiene (S. Sahadzic, United Nations Children's Fund,
Sarajevo, personal communication, 1993).

The limited occurrence of vaccine-preventable diseases in
Bosnia and Herzegovina may reflect high prewar vaccination rates
and the relative absence of crowded camps that have characterized
other refugee emergencies. However, measles epidemics have occurred
in countries with measles vaccine coverage levels of 70% or higher
(8) and the potential for such outbreaks remains high in central
Bosnia.

Even though the availability and distribution of food rations
have been limited in Bosnia, WHO surveys suggest low prevalences of
acute malnutrition. This finding may reflect a combination of four
factors: 1) the presence of substantial household food reserves in
1992 (3); 2) a baseline (i.e. prewar) prevalence of elevated body
mass index (9); 3) effective food distribution efforts by UNHCR
from 1992 until July 1993 (2); and 4) food deliveries by commercial
trucks through regular trade routes from Croatia and Serbia until
April 1993 (3).

This assessment was limited by the degree of underreporting
and diminished sensitivity of currently operating surveillance
systems. Because reports of health status provided by government
sources under such circumstances may be subject to bias,
independent public health surveillance and assessments should be
conducted to ensure the accuracy of such reports.

Priorities for relief efforts in Bosnia and Herzegovina may
differ from those usually recommended for complex disasters in
developing countries (7). Moreover, during 1994, the public health
of residents of this region may be further threatened by lack of
access by international relief agencies, limited food and fuel
reserves, a likely increase in the nutritionally vulnerable
population (especially children, the elderly, and pregnant women),
and the severity of the winter. In addition to the identification
of secure routes of access and transportation of diesel into
central Bosnia, recommendations for immediate action by appropriate
UN agencies and NGOs have included strengthening of programs for
water and sanitation, childhood vaccination, and prenatal care and
expansion of the WHO health monitoring and nutritional surveillance
system.

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